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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_888_Библиотеки_им_академика_М_И_Перельмана
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276
Fig. 20.5 Port placement
for a right-handed surgeon
addressing a lower midline
defects. We initiate the
dissection in the upper
portion of left retrorectus
space. Balloon dissector is
used at port position #1 to
develop the left retrorectus
space, followed by direct
visualization for placement
of port #2 into the
developed space with an
optional port #3. Port #4 is
used as a camera port
Fig. 20.6 Medial aspect
of the left posterior rectus
sheath is incised and the
preperitoneal space entered
just supercial to falciform
ligament
F. M. M. de Oliveira et al.
sharply dissect the distal attachments, thus mobilizing it downward. Alternatively,
the sac can be sharply entered and laparoscopic adhesiolysis performed as
needed.
Transversus Abdominis Release (TAR)
For more complex defects that require large mesh placement, the TAR procedure
is added [9, 10]. We have found that incorporation of TAR is benecial in cases
with wide (>10cm) defects, narrow (<5cm) retrorectus spaces, or when dealing
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Fig. 20.7 The right
posterior rectus sheath is
identied and its medial
aspect incised and then
released in a cephalad to
caudal direction followed
by blunt dissection in the
right retrorectus space
Fig. 20.8 The cut edge of
PRS is retracted medially
revealing the posterior
lamina of the internal
oblique muscle, a thin
layer of connective tissue
covering. Once identied
and incised with hook
electrocautery, the
transversus abdominis
muscle bers can be
appreciated
277
with a poorly compliant abdominal wall. Any defects in the posterior layer are
closed with 2-0 absorbable suture. The abdominal wall defect is primarily closed
using 0 barbed suture in running fashion, while pneumoperitoneum is dropped to
8mmHg.
For defects wider than 10cm, primary fascial closure can rarely be achieved
under physiologic tension unless additional component separation in the form of
TAR is added to the procedure. The edge of the cut posterior rectus sheath (PRS)
on one side is retracted medially, and a thin, almost transparent layer of connective tissue that covers the transversus bers is identied as the posterior lamina
of the internal oblique muscle and incised with hook electrocautery, thus exposing the transversus abdominis muscle bers (Fig.20.8). Care must be taken to
stay medial to the perforating nerves and vessels at the linea semilunaris to maintain functional segmental innervation to the rectus (Fig.20.9). Hook cautery is
used to elevate and transect the exposed transversus bers, revealing the glistening transversalis fascia underneath. This is continued from cephalad to caudad
until the transversalis fascia is seen as a glistening line extending the entire craniocaudal length of the abdominal wall. Blunt dissection is now used to develop
the plane just deeper to the transversus muscle bers and supercial to the transversalis fascia resulting in a retromuscular preperitoneal plane, thereby achieving TAR (Fig.20.10). The plane can be extended in the lateral direction as far as
278
Fig. 20.9 When incising
the lateral edge of the PRS
sheath to expose the
transversus abdominis,
care must be taken to
prevent injury to the
neurovascular bundles near
the linea semilunaris
Fig. 20.10 The
transversalis fascia is
separated from the
transversus abdominis by
blunt dissection achieving
TAR
F. M. M. de Oliveira et al.
the midaxillary line. A unilateral TAR can achieve as much as 7cm of medial
fascial mobilization at the level of the umbilicus. Bilateral TAR can be performed
as needed.
Closure
Posterior layer: The edges of the PRS are sutured together in the midline with 2-0
absorbable or barbed suture starting near the xiphoid process running caudally.
Starting at the dome of the bladder, the surgeon and assistant switch positions, and
suture is run cranially, meeting in the middle where the two sutures are tied
together.
Anterior layer: Pneumoperitoneum is dropped to 8–10mmHg to decrease the
tension placed on the anterior layer closure. The defect being closed is at the top of
the monitor and is sutured “upside down” with back-handed needle driving. A 0
barbed suture is used for this closure due to technical ease of use afforded in this
situation. If a large subcutaneous sac is present, one or more bites of the sac are
included in the suture line for plication in order to reduce the likelihood of developing a postoperative seroma (Fig.20.11). With the previously performed posterior
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Fig. 20.11 Closure of the
anterior layer. A 0 barbed
suture is used in a
back-handed fashion with
an “upside down” view to
take bites of the edges of
the defect while including
the sac (if a large
subcutaneous portion is
present) in between to
reduce the chance of
postoperative seroma
279
CS, the defect edges should come together in a tension-free fashion. The defect is
closed with v-lock suture, completed with four or ve throws run in a backward
fashion.
Mesh Placement
Once both anterior and posterior fascial layers are closed, the mesh is deployed in
the retromuscular sublay position. The developed retromuscular space is measured
for appropriate mesh size selection. Our preference is medium-weight macroporous
polypropylene mesh which is deployed through our 12-mm trocar (Fig. 20.12).
There is no need for antiadhesion barriers as there now exists an autologous barrier
between the mesh and viscera, a signicant advantage of the sublay position. Mesh
placement in the retromuscular space has allowed for the discontinuation of aggressive penetrating xation techniques with transfascial sutures, transitioning rst to
brin glue and, more recently, to complete cessation of mesh xation as our data
illustrates penetrating xation is associated with higher incidence of chronic pain
without the added benet of lowered rates of recurrence. Pneumoperitoneum is
released under direct vision, assuring the mesh is lying at and wrinkle-free between
the posterior and anterior layers.
Formerly, we once placed drains just supercial to the mesh in all hernia repair
cases. We are now more selective with drain placement and do not utilize it for most
patients. To date we have not observed an increase in wound morbidity as a result.
Transabdominal Approach
Alternatively, traditional laparoscopic transabdominal approach can be used.
Standard laparoscopic entry to the peritoneal cavity can be achieved and adhesions
taken down. The PRS is then incised just lateral to the defect or the linea alba.
Dissection can proceed from there as we described in l-TAR originally, prior to our
adoption of the eTEP access approach [11]. This lateral approach comes with higher
degree of difculty on the midline suturing for closure.
280
Fig. 20.12 Placement of a
medium-weight
macroporous
polypropylene mesh
deployed through the
12-mm trocar. There is no
need for antiadhesion
barriers as there now exists
an autologous barrier
between the mesh and
viscera
F. M. M. de Oliveira et al.
Postoperative Management
Patients are transferred from the PACU for admission to the wards or alternatively
discharged to home as determined by the complexity of the surgery and other patient
factors. Those that underwent an eTEP access Rives-Stoppa repair (retrorectus
mesh placement) are typically discharged home the day of surgery. Diet is advanced
as tolerated, and patients are encouraged to ambulate early and often as possible to
prevent postoperative ileus or thromboembolism. The average length of stay at our
center following eTEP access TAR procedures is approximately 1–2days. Prolonged
postoperative ileus, although uncommon, is the primary cause for increased length
of hospital stay.
Patients are discharged from the hospital once they are sufciently ambulating,
tolerating oral intake, have a return of bowel function, and tolerating pain control
without the need for intravenous medications. Typically, patients are seen 4weeks
following surgery for their rst postoperative clinic visit; however, visits are scheduled sooner (typically at 1week) if they are discharged with a drain in place.
MILOS andEMILOS Approaches
Since the space to be dissected is the same of eTEP, the contraindications are the
same for the MILOS approach.
MILOS stands for mini and less open sublay and uses the hernia itself to get
access to the preperitoneal space with a 2–6-cm skin incision directly over the center of the hernia defect, followed by exposure of the hernia sac (this can be widened
for large incisional hernias), as described by Reinpold [12]. The hernia sac can be
opened at this time to inspect the abdominal cavity, and this can be followed by
open or laparoscopic adhesiolysis if necessary. The abdominal wall is lifted with
retractors. After transhernial mini-open dissection of an extraperitoneal space of at
least 8cm in diameter and closing of the peritoneal cavity, one can continue the
procedure as total extra peritoneal gas endoscopy (TEP of the abdominal wall)
using either standard trocars or a transhernial single port. Here the medial aspect of
the posterior rectus sheath is opened under direct vision in both sides of the
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Fig. 20.13 MILOS
technique—Transhernial
exploration with exposition
of the hernia defect [
13]
281
abdominal wall, enabling a large retromuscular pocket that can receive the mesh.
This can be achieved using regular surgical and/or laparoscopic instruments. A special laparoscopic light source with a working channel in his middle designed to
allow the use of regular laparoscopic instruments to dissect this space, normally
without the use of a laparoscopic camera port is suggested [12, 13]. This device is
called EndoTORCH Light Tube® (Richard Wolf GmbH, Knittlingen, Germany).
Very large synthetic meshes can be implanted if the size of the hernia requires it. A
total sublay repair of the abdominal wall can be achieved with excellent results
according to recent publications [12, 13] (Figs. 20.13, 20.14, 20.15, 20.16, 20.17,
and 20.18).
The endoscopic mini/less open sublay (EMILOS) technique consists of a modication described by Reinpold where the dissection of the retromuscular space is
performed in an endoscopic fashion, using regular laparoscopic instruments and
carbon dioxide insufation (or, e.g., using a single port) [14]. The procedure is the
same as for MILOS operation until the transhernial exploration is done [13, 14].
After that the endoscopic part (which stands for the E in EMILOS) of the MILOS
operation starts with the incision of the posterior sheath of the rectus muscle on one
side. The rims of the opened fascia are marked with holding sutures. A sponge forceps is placed into the rectus sheath and directed toward the pubis, in a caudal direction. In the original description, a balloon dissector is positioned down and inated,
creating a space for safe introduction of the camera port. Carbon dioxide is started
at this point, allowing gas to gain the preperitoneal space (sutures at the entrance to
the rectus sheath are xed to the port to avoid leak). In the original description, a
port is placed in this space and the 10-mm port is removed.
At this point, the opposite side of the posterior sheath of the rectus muscle is
incised. These incisions on both sides are continued caudally and cranially as far
as it is convenient in relation to the small skin incision. During this step, the
282
F. M. M. de Oliveira et al.
Linea Alba
Peritoneum
posterior lamina
of the rectus sheath
dorsal view of the
ventral abdominal wall
Fig. 20.14 MILOS technique—Lifting of the abdominal wall with retractors and dissection of the
preperitoneal space. Incision of the medial aspect of the posterior rectus sheath bilaterally to gain
access to retromuscular space [12]
long narrow retractors
anterior lamina
of the rectus
sheath
Fig. 20.15 MILOS
technique—Retromuscular
nal positioning of the
mesh, allowing a big
overlap [12]
abdominal wall is elevated by retractors, always taking care to preserve the linea
alba. Blunt detachment of the posterior sheath of the rectus muscle using the curved
sponge forceps as far as it is possible is accomplished, accompanied by tight closure of the skin incision. The camera is positioned in the lower trocar facing up and
the carbon dioxide insufation restarted, which allows endoscopic visualization of
the retromuscular space with the surgeon standing between the legs and the video
tower behind the head of the patient. Dissection cephalad is achieved after
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Fig. 20.16 EMILOS technique—Positioning of a suprapubic trocar after creating the preperitoneal space downward to the pubis [14]
Fig. 20.17 EMILOS
technique—Trocar
positioning with the
surgeon between patient
legs and dissecting
cephalad. Two port
positioned in the hernia
defect in this picture [
12]
283
introducing 5-mm working trocars on each side laterally to the midline in the
medio-clavicular line and about 3–5cm above of the umbilicus under direct view.
In a comfortable position, the surgeon can continue the incision of the posterior
rectus sheath cranially up to the costal margin and the xiphoid. The space behind
the costal margin as well as behind the sternum (fatty triangle) is easily dissected
and opened for later mesh placement. It is always important to remember to preserve the linea alba; otherwise one will be working on the subcutaneous space.
Detachment of the fascia from the rectus muscle while carefully preserving the
vessels and the nerves perforating the fascia laterally is easily performed.
284
Fig. 20.18 EMILOS
technique—Endoscopic
view of the cephalad aspect
of the dissection [14]
F. M. M. de Oliveira et al.
Introducing a 10-mm optic trocar about 5–7cm superior to the working trocars
under view through the rectus muscle will allow continuation of the incision of the
posterior rectus sheath downward to the arcuate line. The space of Retzius will be
opened, and the dissection may be proceeded down to the pubic bone and below of
the inferior suprapubic trocar.
A large mesh can be positioned in the enormous preperitoneal space prepared
with the dissection described above. Drains are introduced via the 5-mm working
trocars. The skin is reopened, the hernia defect is closed with a nonabsorbable running suture in small bite technique, but the posterior rectus sheath is left open. The
wound is closed and dressed, and an abdominal binder is placed [13, 14].
Onlay MIS Repair: Subcutaneous Onlay Laparoscopic
Approach (SCOLA) andEndoscopic-Assisted Linea Alba
Reconstruction (ELAR)
This technique has previous anecdotal descriptions and consists of performing a
“subcutaneoscopic” dissection and is directed specially to small umbilical and epigastric hernias with concomitant rectus muscle diastasis [15]. Recently, a large
series with description of the technique and results was published [16]. In this subset of patients, if one only corrects the hernia, the patient might still complain of the
abdominal bulge of the rectus diastasis and will result in a higher recurrence rate
[15, 16]. Only correcting the diastasis in an onlay fashion will result in a large scar,
which is unacceptable from a cosmetic standpoint, especially since there’s no true
hernia (and its consequences) in the diastasis part of the operation.
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285
Patient Positioning andTrocar Placement
The patient is positioned supine with the left arm tucked at the side and the right arm
abducted. Another alternative is to open the patient’s legs. The endoscopic equipment is positioned to the left of the patient. The access route consists of a half loop
on the left around the umbilicus, extending 2–3 cm cranially in the midline
(Fig.20.19). Dissection of the umbilical hernia (if present) is performed as usual,
and the anterior layer of the rectus sheath is exposed on both sides from the xiphoid
process and extends several centimeters below the umbilicus. The anterior layer of
the rectus sheath is freed from subcutaneous tissue by diathermy on both sides in a
width of around 4–5cm. The original description uses regular surgical instruments,
but one can use laparoscopic instruments and carbon dioxide insufation if desired.
When using regular instruments, the surgeon has a direct view of the surgical area
via the skin incision but needs the light source to that effect, while the two assistants
watch the monitor of the video endoscopic equipment positioned to the right of the
patient. A more ergonomic approach (SCOLA) is to be positioned in between the
legs, with three ports positioned in the suprapubic area, 6 cm apart each other
(Fig.20.20). A robotic approach can be performed as well, with docking from the
left shoulder after the suprapubic port access.
SC Space Creation andMidline Plication
The surgeon starts the subcutaneous dissection from bottom up, until he or she
reaches the subxiphoid area, going through the entire midline and associated hernias, creating a 15-cm wide space (Fig.20.21). At this point, the surgeon can decide
if only an approximation of the linea alba is necessary or if an incision needs to be
made around 2cm from the medial margin of the rectus sheath to reinforce linea
alba or to allow approximation without tension (described as endoscopic-assisted
linea alba reconstruction—ELAR [15, 16]). If not, the plication can be done with
barbed sutures to facilitate after measuring the space and mesh size required
Fig. 20.19 ELAR—Size of
the mesh (in blue line) and
extent of skin incision [15]
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